printed: 01/03/2018 department of health and human

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

01/03/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

BLOOMINGTON, IN 47401

15G357 11/16/2017

STONE BELT ARC INC

3502 FESTIVE DR

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This visit was for a fundamental

recertification and state licensure survey.

Survey Dates: November 13, 14, 15 and

16, 2017

Facility Number: 000872

Provider Number: 15G357

AIM Number: 100239670

These deficiencies also reflect state findings

in accordance with 460 IAC 9.

Quality Review of this report completed by

#15068 on 11/28/17.

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483.430(e)(1)

STAFF TRAINING PROGRAM

The facility must provide each employee with

initial and continuing training that enables the

employee to perform his or her duties

effectively, efficiently, and competently.

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Based on observation, record review and

interview for 5 of 5 clients living in the group

home (#1, #2, #3, #4 and #5), the facility

failed to ensure the direct care staff received

competency-based training for the use of

client #2's hearing aids, client #2's hypoxia

(deficiency in the amount of oxygen reaching

the tissues) risk plan and staff #4 conducting

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Staff Training Program – The

facility must ensure that direct

care staff receive competency

based training for use of client

hearing aids as well as hypoxia

risk plans. The facility must also

ensure that direct care staff are

trained on conducting drills,

including overnight drills.

12/16/2017 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 433Y11 Facility ID: 000872

TITLE

If continuation sheet of 26

(X6) DATE




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15G357 11/16/2017

STONE BELT ARC INC

3502 FESTIVE DR

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overnight drills.

Findings include:

1) On 11/13/17 from 4:07 PM to 6:19 PM

and 11/14/17 from 5:55 AM to 7:40 AM,

observations were conducted at the group

home. During the observations, when staff

spoke to client #2, the staff used loud voices

to speak to her. Staff was observed to

repeat themselves several times, on

occasion, until client #2 appeared to

comprehend what the staff was asking her to

do.

On 11/13/17 at 4:47 PM, the Home

Manager (HM) indicated client #2 did not

have hearing aids that she was aware of.

The HM stated, "Never seen her wear

hearing aids... Needs them."

On 11/13/17 at 4:57 PM, staff #2 located

one of client #2's hearing aids. Staff #2

indicated she was unsure if the hearing aid

worked or not. Staff #2 indicated she was

unsure if client #2 wore one or two hearing

aids. Staff #2 indicated client #2 refused to

wear her hearing aids. Staff #2 indicated

she was unsure if client #2 had a plan to

address her refusals to wear her hearing aid.

On 11/14/17 at 12:48 PM, a review of

Corrective action for resident(s)

found to have been affected

(1) Staff will be trained on Client

#2’s hearing aids and how best to

encourage usage by Client #2; (2)

Staff will be trained on Client #2’s

hypoxia risk plan; and (3) Staff #4

will be trained on conducting

overnight drills.

How facility will identify other

residents potentially affected &

what measures taken

Hearing aid and Hypoxia training

affects only Client #2. Drill training

potentially affects all residents,

and corrective measures address

the needs of all clients.

Measures or systemic changes

facility put in place to ensure no

recurrence

Stone Belt Nurse will train on

hearing aids and hypoxia risk

plan, Coordinator or QIDP will train

on overnight drills.

How corrective actions will be

monitored to ensure no recurrence

A new Director of Supported

Group Living (SGL) was hired and

will ensure all corrections are in

place and monitored. She

supervises the QIDP and

Coordinator who will provide

monitoring.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet of 26




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15G357 11/16/2017

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3502 FESTIVE DR

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client #2's record was conducted. Client

#2's 9/5/17 Physician's Orders indicated,

"May use hearing aids at her discretion...."

Client #2's most recent hearing examination

(6/22/15) indicated, "(Right) mixed hearing

loss, (left) severe hearing loss

(sensorineural- hearing loss caused by

damage to the inner ear or the nerve from

the ear to the brain) & (and) ETD

(Eustachian Tube Dysfunction - the tube

between the middle ear and the back of the

nose (the Eustachian tube) doesn't work

properly). Follow-up with ENT (Ear, Nose

and Throat doctor). Appointment 6/23/15."

There was no documentation in client #2's

record of an ENT appointment on 6/23/15.

A 9/29/15 Outside Services Report with an

ENT indicated, "...may use hearing aids at

her discretion." Client #2's 7/31/17 Nurse

Quarterly Physical indicated in the Adaptive

Equipment section, "...bilateral hearing

aids...."

On 11/14/17 at 12:07 PM, the nurse stated

she "believed" client #2 had two hearing

aids. The nurse indicated client #2 refused

to wear her hearing aids. The nurse

indicated client #2 purposefully breaks her

hearing aids. The nurse indicated the staff at

the group home should know she has

hearing aids and make them available to her.

The nurse indicated staff needed to be





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15G357 11/16/2017

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3502 FESTIVE DR

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retrained on client #2's hearing aids.

On 11/14/17 at 1:51 PM, the Assistant

Group Home Director (AGHD) indicated

the staff needed to be aware she had hearing

aids and offer them to her. The AGHD

indicated the staff needed to be retrained.

2) An observation was conducted at the

group home on 11/13/17 from 4:07 PM to

6:19 PM. During the medication

administration to client #2, the Home

Manager (HM) informed the surveyor that

client #2's oxygen level would be checked at

her bedtime medication pass. The surveyor

asked the HM if there was a plan for the

staff to implement if client #2's oxygen levels

were low. The HM stated "ideally" there

would be a plan. The HM indicated she

was not aware of a plan. The HM indicated

she wanted the staff to notify the nurse if

client #2's oxygen level was less than 90

percent. The HM indicated there was no

documentation of this in writing.



#2's 5/4/17 Hypoxia risk plan indicated,

"...If [client #2's] O2 (oxygen) levels are

below 88% have [client #2] take deep

breaths in (and) out slowly. Staff will also

encourage [client #2] to walk for 10





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15G357 11/16/2017

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3502 FESTIVE DR

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minutes. If [client #2's] O2 continues to

drop after walking and deep breathing call

the nurse...."

On 11/14/17 at 12:07 PM, the nurse

indicated the staff need to be retrained on

client #2's hypoxia risk plan to ensure they

know what to do when her oxygen levels

were low.

On 11/14/17 at 1:51 PM, the Qualified

Intellectual Disabilities Professional (QIDP)

indicated the staff needed to be retrained on

client #2's risk plan.

3) On 11/14/17 at 6:13 AM, staff #4 (staff

who worked the overnight shift from 10:00

PM to 8:00 AM) indicated she had not

conducted an overnight evacuation drill since

working at the group home. Staff #4 stated

she was "so-so" with the evacuation process

and felt "somewhat comfortable" in

evacuating the clients. Staff #4 indicated she

had worked at the home for approximately

3 months. This affected clients #1, #2, #3,

#4 and #5.

On 11/13/17 at 12:42 PM, a review of the

evacuation drills was conducted. There was

no documentation staff #4 participated in or

conducted evacuation drills at the group

home in the past 6 months during the





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3502 FESTIVE DR

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overnight shift.

On 11/15/17 at 2:53 PM, the QIDP sent

documentation staff #4 received training on

Fire, Drills & (and) Safety on 9/5/17 for

another group home. The QIDP indicated

in the email, "I have attached a training sheet

for [staff #4] that shows that she has been

trained on drill procedures and

documentation." The QIDP did not provide

documentation staff #4 received the training

at client #1, #2, #3, #4 and #5's group

home. There was no documentation staff #4

received training indicating the location of

the fire box, executing a drill, evacuation

procedures, fire watch checklist and the

location of fire extinguishers.

On 11/15/17 at 1:58 PM, the AGHD

indicated staff #4 did not conduct an

overnight drill by herself. The AGHD

indicated staff #4 participated in a drill

during training but she had not completed an

evacuation drill at the group home during the

overnight shift.

9-3-3(a)

483.440(c)(4)

INDIVIDUAL PROGRAM PLAN

The individual program plan states the

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3502 FESTIVE DR

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specific objectives necessary to meet the

client's needs, as identified by the

comprehensive assessment required by

paragraph (c)(3) of this section.

Based on record review and interview for 1

of 3 clients in the sample (#1), the facility

failed to develop a plan to address the

recommendations from client #1's Physical

Therapist.

Findings include:

On 11/14/17 at 11:17 AM, a review of

client #1's record was conducted. On

9/1/17, the Physical Therapist (PT)

recommended the following:

"-Stand patient 5-10 times a day for 1-2

minutes, progress 1-2 minutes every week.

Goal is to stand for 15 minutes at a time.

-Pt (patient) to start standing while changing

[incontinence brief].

-Pt to begin standing in shower to rinse off

@ (at) end for 1-2 minutes. Progress

standing time in shower as able...."

Client #1's record did not include

documentation the PT's recommendations

were implemented. There was no


were incorporated into a plan for staff to

implement. The PT's recommendations

were included on client #1's 11/7/17

Medication Information Sheet. There was

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Individual Program Plan – The

facility must ensure a plan is

developed to address

recommendations from Physical

Therapist.



QIDP, with the assistance of

Stone Belt Nurse, will create a

goal for Client #1’s physical

therapy recommendations and

train staff in implementation of that

goal.



what measures taken

This affects only Client #1



recurrence

QIDP will create a goal for Client

#1’s physical therapy and develop

tracking for progress toward goal

achievement.








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3502 FESTIVE DR

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no documentation indicating a progression

for staff to follow based on the PT's

recommendations. There was no schedule

for the staff to implement indicating where

client #1 was on his progression.


indicated the PT's recommendations were

copied, verbatim, into client #1's Medication

Information Sheet. The nurse indicated

there was no documentation of the

implementation of the recommendations.

The nurse indicated there needed to be a

clear plan for staff to follow and implement.

The nurse stated it "got missed." The nurse

stated the facility needed to "develop a plan

and implement the plan."


Group Home Director indicated client #1

needed to have a plan developed and

implemented. There needed to be


were implemented.



indicated client #1 needed to have a plan

developed and implemented. The QIDP

indicated there needed to be documentation

the PT's recommendations were

implemented.


monitoring.





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3502 FESTIVE DR

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9-3-4(a)

483.440(d)(1)

PROGRAM IMPLEMENTATION

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient

number and frequency to support the

achievement of the objectives identified in the

individual program plan.

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interview for 1 of 3 clients in the sample (#3)

and one additional client (#4), the facility

failed to ensure the clients were engaged in

active treatment and meaningful activities.

Findings include:

Observations were conducted at the group

home on 11/13/17 from 4:07 PM to 6:19

PM and 11/14/17 from 5:55 AM to 7:40

AM:

-During a majority of the observations, client

#3 sat on the couch in the living room with a

magazine (during the evening observation) or

a straw (during the morning observation).

Client #3 was not engaged by staff with the

exception of receiving her medications or

during meals. The remainder of the

observations, client #3 sat on the couch.

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Program Implementation – The

facility must ensure that clients

are engaged in active treatment

and meaningful activities.



Team will develop activities for

Clients #3 and #4 based on their

respective ISP goals.

Coordinator/QIDP will develop

schedules that engage these

clients in active treatment and

meaningful activities.



what measures taken

All residents potentially are

affected, and corrective measures

address the needs of all clients.



recurrence

Coordinator and QIDP will review

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3502 FESTIVE DR

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Client #3 was not engaged in meaningful

activities. Client #3's active treatment

schedule was not implemented. Client #3

did not assist with making breakfast or

dinner.


#4 was in a wheelchair moving from the

dining room, living room and hallway. Client

#4 was holding a magazine most of the time

she was sitting in her wheelchair. Client #4

was not engaged by staff with the exception

of receiving her medications or during meals.




did not assist with putting away her laundry.

Client #4 did not assist with making her

breakfast.

On 11/14/17 at 1:13 PM, a review of client

#3's record was conducted. Client #3's

3/27/17 Individualized Support Plan (ISP)

indicated she had the following goals and

objectives: participate in

occupational/physical therapy exercises,

increase her communication skills,

medication administration skills and

ambulating safely.

On 11/14/17 at 2:04 PM, a focused review

of client #4's record was conducted. Client

#4's 7/25/17 ISP indicated she had the

activities and schedules for all

clients. Coordinator/QIDP will also

review client billing

documentation for each client at

least weekly as a means of

ensuring that staff are actively

engaging the clients in meaningful

activities.



The facility will monitor on site

through unannounced visits to the

home for direct observation by the

Coordinator/QIDP to ensure staff

are following the schedule and

engaging clients in active

treatment. A new Director of

Supported Group Living (SGL) was

hired and will ensure all

corrections are in place and

monitored. She supervises the

QIDP and Coordinator who will

provide monitoring.





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15G357 11/16/2017

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3502 FESTIVE DR

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following goals and objectives: increase her

choice making by grabbing/reaching for an

item, increase her communication skills,

participate in community activities, sensory

activities and safe use of her wheelchair by

not running into others.



indicated the clients should be engaged in

meaningful activities. The QIDP indicated

the clients should be prompted to participate

in their goals and objectives. The QIDP

indicated the staff should prompt the clients

to engage in activities at least every 15

minutes.



the clients should be engaged in meaningful

activities. The AGHD indicated the clients

should be prompted to participate in their

goals and objectives. The AGHD indicated

the staff should prompt the clients to engage

in activities at least every 15 minutes.

9-3-4(a)

483.440(d)(2)

PROGRAM IMPLEMENTATION

The facility must develop an active treatment

schedule that outlines the current active

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3502 FESTIVE DR

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treatment program and that is readily

available for review by relevant staff.


interview for 1 of 3 clients in the sample (#3)

and one additional client (#4), the facility

failed to ensure the clients had current active

treatment schedules for the staff to

implement.

Findings include:

Observations were conducted at the group

home on 11/13/17 from 4:07 PM to 6:19

PM and 11/14/17 from 5:55 AM to 7:40

AM:


#3 sat on the couch in the living room with a

magazine (during the evening observation) or

a straw (during the morning observation).

Client #3 was not engaged by staff with the

exception of receiving her medications or

during meals. The remainder of the

observations, client #3 sat on the couch.




did not assist with making breakfast or

dinner.


#4 was in a wheelchair moving from the

dining room, living room and hallway. Client

#4 was holding a magazine most of the time

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Program Implementation – Facility

must ensure that clients have

active treatment schedules for

staff to implement.



Team will develop activities for

Clients #3 and #4 based on their

respective ISP goals and will

develop schedules that engage

these clients in active treatment.



what measures taken






recurrence

Coordinator with assistance of

QIDP will review activities, daily

schedules and implementation by

staff.









monitoring.

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she was sitting in her wheelchair. Client #4

was not engaged by staff with the exception

of receiving her medications or during meals.




did not assist with putting away her laundry.

Client #4 did not assist with making her

breakfast.

On 11/14/17 at 1:13 PM, a review of client

#3's record was conducted. There was no

documentation in her record of an Active

Treatment Schedule. On 11/14/17 at 2:04

PM, the Assistant Group Home Director

(AGHD) provided an undated Active

Treatment Schedule. Based on the

information on the AGHD's computer, the

Active Treatment Schedule was last updated

in August 2015. Client #3's Active

Treatment Schedule indicated the following:

"-6:00 AM to 6:20 AM - Wake [client #3],

help make her bed, help her put away

laundry if needed. Help [client #3] pick out

clothes for the day. Assist her with rest

rooming & (and) shower, assist her with

brushing teeth and getting dressed. Morning

meds.

-6:20 AM to 6:50 AM - Help make

breakfast.

-6:50 AM to 7:00 AM - Get ready for

breakfast.





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-7:00 AM to 7:20 AM - Breakfast.

-7:20 AM to 7:30 AM - Restroom/shoes.

-7:30 AM - Get in van and go to day

program.

-4:30 PM to 4:45 PM - Restroom and

possibly PJ's

-4:45 PM to 5:00 PM - TV time/help with

dinner

-5:00 PM to 6:00 PM - Dinner.

-6:00 PM to 6:30 PM - Magazine and TV

time...."

On 11/14/17 at 2:04 PM, a focused review

of client #4's record was conducted. Client

#4's undated Active Treatment Schedule

(August 2015 based on when the document

was last updated on the AGHD's computer)

indicated the schedule had not been updated

since August 2015.

Client #4's Active Treatment Schedule

indicated the following:

"-6:00 AM to 6:20 AM - Morning meds.

-6:20 AM to 6:50 AM - Help make

breakfast.

-6:50 AM to 7:00 AM - Get ready for

breakfast.

-7:00 AM to 7:20 AM - Breakfast.

-7:20 AM to 7:30 AM - Restroom. Shoes

get in wheelchair for day program.

-7:30 AM - Get in van and go to day

program.

-4:30 PM to 4:45 PM - Restroom and





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possibly PJ's

-4:45 PM to 5:00 PM - Meds

-5:00 PM to 6:00 PM - Dinner.

-6:00 PM to 6:30 PM - Hang out around

the house...."

On 11/14/17 at 2:04 PM, the AGHD

indicated the clients' Active Treatment

Schedules should be reviewed and updated

annually.

9-3-4(a)

483.460(a)(3)

PHYSICIAN SERVICES

The facility must provide or obtain preventive

and general medical care.

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of 3 clients in the sample (#1), the facility

failed to ensure client #1 had an annual

physical.

Findings include:



#1's most recent annual physical was

conducted on 9/16/16. There was no

documentation client #1 had an annual

physical since 9/16/16.


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Physician Services – Facility will

ensure that clients have an annual

physical.



Day Aide will schedule and

arrange transport for Client #1 to

his annual physical



what measures taken





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indicated client #1 should have a physical

annually.

On 11/15/17 at 11:25 AM, the Qualified

Intellectual Disabilities Professional indicated

in an email when asked if there was

documentation of an annual physical for

client #1, "He did not. He is scheduled for

one in early December."

9-3-6(a)


recurrence

Day Aide will review all client files

to ensure that annual physicals

are up to date and if not,

appointments will be scheduled.









monitoring.

483.460(c)

NURSING SERVICES

The facility must provide clients with nursing

services in accordance with their needs.

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of 3 clients in the sample (#1), the facility's

nursing services failed to ensure a plan was

developed, implemented and documented

based on the Physical Therapist's (PT)

recommendations on 9/1/17.

Findings include:


client #1's record was conducted. On

9/1/17, the PT recommended the following:

"-Stand patient 5-10 times a day for 1-2

minutes, progress 1-2 minutes every week.

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Nursing Services – Facility nursing

services must ensure a plan is

developed, implemented, and

documented based on physical

therapist recommendations.



QIDP, with the assistance of

Stone Belt Nurse, will create a

goal for Client #1’s physical

therapy recommendations and

train staff in implementation of that

goal.



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Goal is to stand for 15 minutes at a time.

-Pt (patient) to start standing while changing

diaper.

-Pt to begin standing in shower to rinse off

@ (at) end for 1-2 minutes. Progress

standing time in shower as able...."

Client #1's record did not include


were implemented. There was no


were incorporated into a plan for staff to

implement. There was no documentation

the staff received training on client #1's PT

recommendations. The PT's

recommendations were included on client

#1's 11/7/17 Medication Information Sheet.

There was no documentation indicating a

progression for staff to follow based on the

PT's recommendations. There was no

schedule for the staff to implement indicating

where client #1 was on his progression.


indicated the PT's recommendations were

copied, verbatim, into client #1's Medication

Information Sheet. The nurse indicated

there was no documentation of the

implementation of the recommendations.

The nurse indicated there needed to be a

clear plan for staff to follow and implement.

The nurse stated it "got missed." The nurse

what measures taken




recurrence

QIDP will create a goal for Client

#1’s physical therapy and develop

tracking for progress toward goal

achievement.









monitoring.





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stated the facility needed to "develop a plan

and implement the plan."


Group Home Director indicated client #1

needed to have a plan developed and

implemented. There needed to be


were implemented.



indicated client #1 needed to have a plan

developed and implemented. The QIDP

indicated there needed to be documentation

the PT's recommendations were

implemented.

9-3-6(a)

483.460(j)(4)

DRUG REGIMEN REVIEW

An individual medication administration

record must be maintained for each client.

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interview for 1 of 1 client (#3) observed to

receive her medications during the morning

medication administration from staff #2, the

facility failed to ensure staff #2 initialed the

Medication Administration Record (MAR)

after administering client #3's medications.

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Drug Regimen Review – Facility

must ensure that staff are trained

in Medication Administration

documentation, including initialing

the MAR after administering client

medication.



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Findings include:

On 11/14/17 from 5:55 AM to 7:40 AM,

an observation was conducted at the group

home. At 6:00 AM prior to administering

client #3's medications, staff #2 initialed

client #3's November 2017 MAR indicating

client #3's medications were administered.

Staff #2 closed client #3's medication

administration binder and put it away prior

to administering client #3's medications.


indicated staff #2 should have administered

client #3's medications and then

signed/initialed the MAR.

9-3-6(a)

All staff will have updated training

on Medication Administration

procedure



what measures taken






recurrence

Updated training on Medication

Administration documentation will

be provided to staff









monitoring.

483.470(g)(2)

SPACE AND EQUIPMENT

The facility must furnish, maintain in good

repair, and teach clients to use and to make

informed choices about the use of dentures,

eyeglasses, hearing and other

communications aids, braces, and other

devices identified by the interdisciplinary

team as needed by the client.

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Based on observation, interview and record

review for 1 of 3 clients in the sample with

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adaptive equipment (#2), the facility failed to

ensure client #2's hearing aids were

maintained in working order and she was

taught to use her hearing aids.

Findings include:

On 11/13/17 from 4:07 PM to 6:19 PM

and 11/14/17 from 5:55 AM to 7:40 AM,

observations were conducted at the group

home. During the observations, when staff

spoke to client #2, the staff used loud voices

to speak to her. Staff was observed to

repeat themselves several times, on

occasion, until client #2 appeared to

comprehend what the staff was asking her to

do.

On 11/13/17 at 4:47 PM, the Home

Manager (HM) indicated client #2 did not

have hearing aids that she was aware of.

The HM stated, "Never seen her wear

hearing aids... Needs them."

On 11/13/17 at 4:57 PM, staff #2 located

one of client #2's hearing aids. Staff #2

indicated she was unsure if the hearing aid

worked or not. Staff #2 indicated she was

unsure if client #2 wore one or two hearing

aids. Staff #2 indicated client #2 refused to

wear her hearing aid. Staff #2 indicated she

was unsure if client #2 had a plan to address

facility must ensure that client

hearing aids are maintained in

working order and clients are

taught to use their hearing aids.



Day Aide will schedule an

appointment for Client #2 with her

ENT to check that hearing aids

are in proper order and provide

training to Client #2 on how to use

her hearing aids.



what measures taken




recurrence

QIDP will ensure that this

appointment is completed and

information transmitted to other

staff as needed.









monitoring.





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her refusals to wear her hearing aid.



#2's 9/5/17 Physician's Orders indicated,

"May use hearing aids at her discretion...."

Client #2's most recent hearing examination

(6/22/15) indicated, "(Right) mixed hearing

loss, (left) severe hearing loss

(sensorineural- hearing loss caused by

damage to the inner ear or the nerve from

the ear to the brain) & (and) ETD

(Eustachian Tube Dysfunction - the tube

between the middle ear and the back of the

nose (the Eustachian tube) doesn't work

properly). Follow-up with ENT (Ear, Nose

and Throat doctor). Appointment 6/23/15."

There was no documentation in client #2's

record of an ENT appointment on 6/23/15.

A 9/29/15 Outside Services Report with an

ENT indicated, "...may use hearing aids at

her discretion." Client #2's 7/31/17 Nurse

Quarterly Physical indicated in the Adaptive

Equipment section, "...bilateral hearing

aids...."

On 11/14/17 at 12:07 PM, the nurse stated

she "believed" client #2 had two hearing

aids. The nurse indicated client #2 refused

to wear her hearing aids. The nurse

indicated client #2 purposefully breaks her

hearing aids. The nurse indicated the staff at





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the group home should know she has

hearing aids and make them available to her.

The nurse indicated she was not aware of a

plan to teach client #2 to wear her hearing

aids. The nurse stated, "there needs to be a

plan." The nurse stated there was no

documentation in client #2's record her

hearing aids had been checked/assessed

since December 2014.



client #2 should have two hearing aids. The

AGHD indicated client #2 broke one of her

hearing aids. The AGHD indicated client #2

could refuse to wear her hearing aids. The

AGHD indicated client #2, in the past, left

her hearing aids in order to lose them. The

AGHD indicated client #2's hearing aids

should be functional and made available to

her. The AGHD indicated client #2 needed

a plan to teach her to use her hearing aids.



indicated one of the hearing aids was

missing. The QIDP indicated client #2's

hearing aids needed to be made available to

her to wear.

On 11/14/17 at 1:44 PM, the Coordinator

indicated client #2's hearing aids should be





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available for her to wear.

9-3-7(a)

483.470(i)(1)

EVACUATION DRILLS

The facility must hold evacuation drills at

least quarterly for each shift of personnel.

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of 5 clients living in the group home (#1, #2,

#3, #4 and #5), the facility failed to conduct

quarterly evacuation drills for each shift of

personnel.

Findings include:


facility's evacuation drills was conducted.

During the night shift (10:00 PM to 6:00

AM), the facility failed to conduct

evacuation drills from 6/21/17 to 11/13/17.

This affected clients #1, #2, #3, #4 and #5.

On 11/14/17 at 6:13 AM, staff #4 (staff

who worked the overnight shift from 10:00

PM to 8:00 AM) indicated she had not

conducted an overnight evacuation drill since

working at the group home. Staff #4 stated

she was "so-so" with the evacuation process

and felt "somewhat comfortable" in

evacuating the clients. Staff #4 indicated she

had worked at the home for approximately

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Evacuation Drills – Facility must

ensure that evacuation drills are

conducted quarterly for each shift

of personnel.



The drill schedule in place did not

have sufficient variation of shifts. A

new schedule will be developed

and implemented by QIDP.



what measures taken






recurrence

Evacuation scheduled will be

revised and implemented in the

home, monitored by Coordinator

and QIDP.



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3 months.


Group Home Director indicated the facility

should conduct one drill per shift per

quarter.

On 11/14/17 at 10:43 AM, the Coordinator

indicated the facility should conduct one drill

per shift per quarter.

9-3-7(a)






Coordinator and will provide

training and monitoring.

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State Findings

The following Community Residential

Facilities for Persons with Developmental

Disabilities Rules were not met:

460 IAC 9-3-3 Facility Staffing

(e) Prior to assuming residential job duties

and annually thereafter, each residential staff

person shall submit written evidence that a

Mantoux (5TU, PPD) tuberculosis skin test

or chest x-ray was completed. The result of

the Mantoux shall be recorded in millimeter

of induration with the date given, date read,

and by whom administered. If the skin test

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Facility Staffing – Facility must

ensure that annual Mantoux

tuberculosis screenings are

conducted.



Mantoux tuberculosis screenings

will be completed for staff



what measures taken






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result is significant (ten (10) millimeters or

more), then a chest film shall be done with

other physical and laboratory examinations

as necessary to complete a diagnosis.

Prophylactic treatment shall be provided as

per diagnosis for the length of time

prescribed by the physician.

This state rule was not met as evidenced by:


of 3 staff (#2), the facility failed to ensure

annual Mantoux (5TU, PPD) tuberculosis

(TB) screenings were conducted.

Findings include:


employee's files was conducted. Staff #2's

most recent TB test was conducted on

10/10/16. There was no documentation

staff #2 had an annual TB test since

10/10/16.


Group Home Director indicated the staff

should have an annual TB test.


indicated the staff should have an annual TB

test.

recurrence

A new Organizational

Effectiveness Coordinator has

been hired and will develop a

tracking system for these

screenings. Monthly reminders will

be developed for staff from this

tracking with alerts also going to

Coordinator and QIDP for follow

up.









monitoring.





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9-3-3(e)


printed: 01/03/2018 department of health and human

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